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Child care case establishes precedent regarding fraudulent billing

A southern Minnesota county, in consultation with the DHS Office of Inspector General (OIG), successfully excluded a childcare center from receiving public funding for one year due to fraudulent billing.

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Fraud Investigations

The Minnesota Department of Human Services Office of Inspector General, in collaboration with county agencies, works to prevent public assistance fraud. The following illustrate cases where people were convicted of various types of fraud and either were required to pay back money or had their funding stopped. If you have a tip or complaint about potential fraud, report it.

Child care case establishes precedent regarding fraudulent billing

A southern Minnesota county, in consultation with the DHS Office of Inspector General (OIG), successfully excluded a childcare center from receiving public funding for one year due to fraudulent billing.
The county’s investigation showed that the center inflated its attendance records. On four different occasions, childcare personnel visited the center and observed fewer children than the center reported on its attendance records. The center billed the state for more children than were listed on daily attendance records, and more children than were observed. This case is important for several reasons. Because the appropriate standard of evidence was found to be a preponderance of evidence, and not the higher standard of clear and convincing evidence, it will make it easier for counties to clamp down on intentional program violations against childcare centers that defraud the state. This means counties need only establish that it is more likely than not that a provider engaged in the intentional program violation. Also, this case establishes that counties can successfully determine a center’s intent to defraud by using circumstantial evidence. In other words, if a county can show many circumstances consistent with the intent to defraud, the circumstances can be considered sufficient without having to introduce direct testimony or evidence of fraud. As such, this case should significantly benefit counties interested in pursuing childcare providers through the administrative disqualification hearing process. The OIG legal unit is available to answer any questions or concerns related to this case. Please contact the OIG at 651-431-4328 or James.Ortmann@state.mn.us.
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Central MN couple required to pay restitution for fraudulently receiving public assistance

A fraud case against a Central Minnesota couple who received public assistance yet failed to report their income ended with the couple being convicted and paying restitution totaling $60,745.
The husband had an unreported job in Crow Wing County. In addition, a fraud prevention investigator (FPI) discovered the couple owned a semi-truck licensed in North Dakota and worked for a company in that state. This business had been operating the entire time the couple received public assistance. The North Dakota company that employed the individuals provided the investigator with their IRS Miscellaneous income form for two years indicating that they grossed over $100,000 each year. When the FPI tried to contact the couple regarding their work, they never responded so the case was turned over to a criminal investigator. The criminal investigator also received no response on requests for information. Ultimately this case was charged in court and the couple pled guilty. Although given the opportunity to provide expenses against their income, they never complied. They were charged with wrongfully obtaining assistance and required to pay restitution.
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Health care owner shut down for defrauding Medical Assistance

The owner of a Minneapolis Home Health Care agency was terminated as a Minnesota Health Care Programs (MHCP) provider in October 2013 as a result of his federal conviction for defrauding Medical Assistance.
The individual owned Lucky Home Health Care. His conviction for defrauding Medicaid is a result of submitting fraudulent billings in excess of $400,000 from January 2008 through June 2011. The individual submitted claims that falsely indicated that home health care services were provided. Home health care is one of the services reimbursed by the Medical Assistance program. The case stems from an investigation by the FBI.
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Metro area provider terminated for Medical Assistance fraud

A metro area man was convicted in December 2013 with a combination of aiding and abetting Medical Assistance fraud and aiding and abetting theft.
The man was a provider in the Minnesota Health Care Programs, providing personal care assistants to Medical Assistance recipients. The metro area man submitted false claims to DHS and Blue Cross Blue Shield (BCBS) that resulted in an overpayment of $75,000 from both DHS and BCBS. DHS withheld MHCP payments until the man was later terminated as a provider based on the conviction. The case was originally investigated by the Surveillance and Integrity Review Section of the DHS Office of Inspector General and referred to the Minnesota Attorney General’s Office/Medicaid Fraud Control Unit (MFCU). In a related case, a personal care attendant (PCA) who worked for the agency was convicted of theft, required to pay $7,000 in restitution to DHS, and not allowed to work for any program that received Medicaid funding for submitting false PCA timecards. The PCA was subsequently terminated by SIRS based on the MFCU conviction.
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PCA suspended, required to pay restitution for falsely claiming work hours

A personal care attendant who submitted time cards that overlapped with other employment was charged with two counts of theft by false representation.
Carrie Lee Riley was accepted into Ramsey County’s Project Remand diversion program and is paying $12,000 in restitution.
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PCA convicted of theft by false representation

In another Ramsey County case, personal care attendant Linda Marie Bryant submitted time cards that overlapped with other employment.
She was convicted in January 2014 of theft by false representation and sentenced to 15 days in jail, three years of probation, 15 days of electronic home monitoring, and will not be allowed to work again in any Medicaid-funded facility. In addition, Bryant is required to pay $6,666 in restitution as well as fees and fines.
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Advantage Home Care Services, Inc. terminated as state health care provider

An investigation into Advantage Home Care Services in 2009 revealed that 53 percent of its submitted claims were improper, documentation was lacking to support billing services, and many employed PCAs had not undergone background studies.
DHS investigators referred the case to the Minnesota Attorney General’s Office, Medicaid Fraud Control Unit, for criminal investigation. Blessing and Ernest Anyanwu were charged with Medical Assistance fraud and theft by false representation in Ramsey County District Court. Both were ordered to pay $15,000 in restitution in November 2013. In addition, Advantage Home Care Services, Inc. was terminated as a provider in Minnesota Health Care Programs.
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Provider terminated for falsely representing PCA services

Marisa Patrice Leggett was convicted of theft by false representation in September 2013 for signing PCA timecards when the actual services were not provided.
Leggett was required to pay $19,500 in restitution, served 60 days in the workhouse, and can no longer work in any Medicaid-funded facility.
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Restitution ordered for woman involved in improper billing

A Chippewa County woman pleaded guilty in district court to one count of theft by false representation.
Susan Jo Enevoldsen, also known as Susan Jo Storch, submitted timesheets claiming to provide PCA services when her client was at an adult day training and habilitation center. Investigators determined Enevoldsen falsely reported 109 days where claims were made for hours not worked in 2009 and 2010, resulting in an overpayment of $930. Enevoldsen was sentenced to 90 days in the Chippewa County Jail, which was stayed for one year, as well as one year of probation. She is prohibited from working in a facility, business or agency where Medicaid or Medicare funds are received. In addition, Enevoldsen can’t accept any employment or appointments involving any contact with vulnerable adults or where Medicaid or Medicare funds are received during her probation. She was ordered to pay $23,488 in restitution.
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Ramsey County woman charged with Medical Assistance fraud

DHS received information about a personal care assistant (PCA) agency owned by Veronica Garley that was involved in improper billing and other wrongdoing.

The DHS SIRS unit completed an investigation and identified overpayments totaling $50,350. Some of the issues identified by SIRS were:

  • no documentation for billed services
  • units billed in excess of documentation
  • incomplete PCA timecards
  • duplicate timecards for the same recipient at the same time
  • incomplete care plans
  • PCA services provided by disqualified individuals or without appropriate supervision
  • inadequate documentation of qualified professional supervision of PCA services.

SIRS referred the case to the Attorney General’s Medicaid Fraud Control Unit (MFCU), which further investigated MaxiCare over a different period of time. MFCU identified $90,459 in overpayments to the company. Owner Garley was charged with two counts of Medical Assistance fraud and one count of theft of medical costs. Garley pleaded guilty and was convicted of gross misdemeanor Medical Assistance Fraud in Ramsey County District Court on December 29, 2014. Garley paid $60,000 in restitution and was ordered to serve seven days in the Ramsey County Correctional Facility. As a condition of her probation, she is prohibited from running or being employed by any company that receives Medicare and/or Medicaid funds.

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